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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid production. It is available in oral and intravenous formulations.
## Primary Indications
* Gastroesophageal reflux disease (GERD) - symptomatic relief and healing of erosive esophagitis.
* Healing of duodenal ulcers.
* H. pylori eradication (in combination with antibiotics).
* Zollinger-Ellison syndrome.
## Adult Dosing
* **GERD (symptomatic):** 20 mg orally once daily.
* **GERD (erosive esophagitis healing):** 40 mg orally once daily for 4 to 8 weeks.
* **Duodenal Ulcers:** 40 mg orally once daily for 2 to 4 weeks.
* **H. pylori Eradication:** 40 mg orally twice daily for 7 days (in combination with specific antibiotics).
* **Zollinger-Ellison Syndrome:** 40 mg orally twice daily initially. Dose may be adjusted based on response, with typical maintenance doses ranging from 40 mg to 80 mg twice daily. Maximum daily dose is typically 160 mg.
* **Intravenous:** 40 mg IV once daily.
## Pediatric Dosing
Dosing in pediatric patients is often weight-based and may vary based on indication and age. Specific protocols should be followed.
* **GERD (erosive esophagitis):**
* Children 5 to 11 years: 20 mg orally once daily for up to 8 weeks.
* Children 12 to 16 years: 40 mg orally once daily for up to 8 weeks.
* **Intravenous:** Limited data in pediatric patients; consult specific guidelines.
## Dose Adjustments
No dose adjustment is typically required for hepatic or renal impairment. However, caution is advised in severe hepatic impairment.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
* Use of rilpivirine-containing products.
## Adverse Effects
Common adverse effects include headache, diarrhea, nausea, abdominal pain, and dizziness. Long-term use of PPIs has been associated with an increased risk of:
* Bone fractures (hip, wrist, spine).
* Clostridium difficile infection.
* Vitamin B12 deficiency.
* Hypomagnesemia.
* Rebound acid hypersecretion upon discontinuation.
## Key Drug Interactions
* **Drugs Dependent on Gastric pH for Absorption:** PPIs can decrease the absorption of drugs such as ketoconazole, itraconazole, and certain HIV protease inhibitors (e.g., atazanavir).
* **Methotrexate:** PPIs may increase serum levels of methotrexate.
* **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Caution may be needed when co-administered with drugs that are substrates of this enzyme (e.g., clopidogrel, though clinical significance is debated).
## Monitoring
* Monitor for improvement of GERD symptoms or healing of esophagitis/ulcers.
* Monitor electrolytes (magnesium, sodium, potassium) with long-term therapy.
* Assess for signs and symptoms of C. difficile infection.
* Consider vitamin B12 levels with prolonged use.
## Clinical Pearls
* Administer oral pantoprazole 30 minutes before a meal for optimal efficacy.
* Delayed-release tablets should be swallowed whole and not chewed or crushed.
* IV pantoprazole should be administered as an infusion over at least 15 minutes.
* Discontinuation of long-term PPI therapy should be considered for gradual tapering to avoid rebound acid hypersecretion.
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*This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always verify current prescribing information with the latest official drug monographs or formularies.*
